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DEFINITIONS OF KEY TERMS 36 PRACTICE GUIDELINES The committee began by defining the term guidelines because it appears to be the term most commonly and comprehensively used in professional and policy discussions. It is employed in this general way in the legislation establishing AHCPR. Common Usage: The Dictionary The Random House Dictionary of the English Language (1987) dates the American origin of guideline to 1775â1785, presumably in its literal usage as a "rope or cord that serves to guide one's steps especially over rocky terrain, through underground passages, etc." Its more metaphorical useâ"any guide or indication of a future course of action"âis a recent addition. The verb ''to guide" is given several meanings including "to supply with advice or counsel." This dictionary notes that the term "implies continuous presence or agency in showing or indicating a course" as distinct from pilot, steer, escort, direct, or lead. The Compact Edition of the Oxford English Dictionary (OED) (1971) does not define guideline directly but includes it in a set of examples of attributes of technical appliances and machinery parts (e.g., guideline for a saw). It defines the verb "to guide" in much the same way as above: to direct the course of (a physical action, for instance) and to lead in a course of action or the direction of events. Professional and Technical Usage American Medical Association (AMA) (J. Kelly, director of the Office of Quality Assurance, letter dated April 26, 1990): "Guideline: Recommendation for patient management which identifies a particular management strategy or a range of management strategies. Practice parameters: Strategies for patient management developed to assist physicians in clinical decisionmaking." The Forum (S. King, Forum director, personal communication, January 1990): "A guideline is a description of the process of care which will permit health to improve, and which has the potential of improving the quality of medical decisionmaking" (provisional definition). U.S. General Accounting Office (G. Silberman, assistant director, Program Evaluation and Methodology Division, letter dated October 16, 1989, to medical specialty societies): "[G]uidanceâby whatever nameâthat aids practicing physicians and others in the medical community (and consumers, if included) in day- to-day decisions by describing the degree of appropriateness and the relative effectiveness of alternate approaches to detecting,
DEFINITIONS OF KEY TERMS 37 diagnosing, and/or managing selected health conditions" (working definition). IOM (1990:304): "Appropriateness guidelines describe accepted indications for using particular medical interventions and technologies, ranging from surgical procedures to diagnostic studies." Joint Commission on Accreditation of Healthcare Organizations (1989a): A guideline gives "indications or contraindications for appropriate patient care." Physician Payment Review Commission: (1) "Practice guidelines are standardized specifications for care, either for the use of a particular service [e.g., preventive screening] or procedure or for the management of a specific clinical problem" (1988a:13). (2) "[Practice guidelines refer to] formally developed guidelines based on the clinical research literature and the collective judgments of experts" (1988b:223). (3) ". . .[E]ssentially clinical recommendations for patient care. They provide guidance to physicians and others who must make decisions. . ." (1988b:223). U.S. Preventive Services Task Force (1989:xxxvii): "Recommendations appearing in this report are intended as guidelines, providing clinicians with information on the proven effectiveness of preventive services in published clinical research. Recommendations for or against performing these maneuvers should not be interpreted as standards of care but rather as statements regarding the quality of the supporting scientific evidence." Mark Chassin (1988): "They [standards of care or practice guidelines] are statements describing specific diagnostic or therapeutic maneuvers that should or should not be performed in certain specific clinical circumstances." David Eddy (forthcoming): "Pathway guidelines (protocols and algorithms) are intended to direct a practitioner along a preferred management path. Boundary guidelines (limits or criteria) are intended to define the limits of proper practice." In distinguishing different types of practice policies (standards, guidelines, and options), Eddy states: "A practice policy is considered a guideline if the outcomes of the intervention are well enough understood to permit meaningful decisions about its proper use, and if it is preferred (or not preferred) by an appreciable but not unanimous majority of people." (Note in the section below that Eddy requires more stringent agreement for a standard.) Lucien Leape (1990:43): Practice guidelines are "standardized specifications for care developed by a formal process that incorporates the best scientific evidence of effectiveness with expert opinion."
